MEDICARE: SHANNON WALTER LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA00006202	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0036825	OTHER	WA	LABOR & INDUSTRY PROVIDER
2	5529WA	OTHER	WA	REGENCE BLUE SHIELD
3	3810WA	OTHER	WA	REGENCE BLUE SHIELD
4	MA00006202	OTHER	WA	MASSAGE LICENSE NUMBER

General Provider Information

NPI Number	:	1912046772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON WALTER LMP

Provider Business Mailing Address
First Line	:	2304 14TH ST
Second Line	:
City	:	ANACORTES
State	:	WA
Zip	:	98221-2053
Country	:	US
Telephone Number	:	360-333-8361
Fax Number	:

Provider Business Practice Location Address
First Line	:	3810 166TH PL NE
Second Line	:	SUITE 201-A
City	:	ARLINGTON
State	:	WA
Zip	:	98223-8402
Country	:	US
Telephone Number	:	360-333-8361
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	07/08/2007

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Directions to “ SHANNON WALTER LMP” Practice Location

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